Sticking Point: How Do We Educate Vaccine-resistant Parents Without Driving Them Away?

As of June 6, nearly 400 cases of measles had been reported in the United States this year. That is by far the highest total since public health officials declared the disease eradicated in this country in 2000. The 16 separate outbreaks in 20 states have led me to think a lot about the spread of vaccine-preventable illness and what I want my clinic policy to be regarding the care of unvaccinated patients.

The highest numbers of cases have been reported from California, Ohio and New York City. Back in April when California had "only" 58 reported cases (close to the yearly national average), the CDC reported that at least 11 people had been infected in doctors’ offices, hospitals or other health care settings. There also have been outbreaks of mumps, pertussis and varicella in various parts of the country in the past year, making the chances of encountering one or another of these vaccine-preventable illnesses in our practices much more likely than in prior years.

The combination of recent disease outbreaks and parents who decline vaccinations has raised concerns about protecting infants too young to be immunized and patients who are immunocompromised when they visit our practices.

Since starting my practice, I have wrestled with how to best provide a safe and protective environment for patients while respecting the choices they make, even when I do not agree with those choices. I fear the possibility of disease transmission from an unvaccinated patient to an infant too young to be immunized or an immunocompromised patient who could also be in my waiting room. That is a distinct possibility because measles spreads easily through the air, and infectious droplets can linger for as long as two hours after a sick person leaves.

If an unvaccinated person comes into contact with measles, there is a 90 percent chance that person will contract the disease, and for every 1,000 children with measles, one or two will die. A recent commentary in the Annals of Internal Medicine stated, "We must ensure that our facilities do not become centers for secondary measles transmission." I have had the argument put to me that people could come in contact with these diseases at the grocery store or the library, and this is true. However, I have no control over those environments, and I haven’t encouraged my patients to go to those places like I have encouraged them to come and see me.

There are physicians who have chosen to stop seeing patients who are unvaccinated. Although I can understand that position, this is not the direction I have chosen to take because I want to have every opportunity possible to educate parents and encourage vaccination. The American Academy of Pediatrics policy on this issue states that physicians "should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child." Should the physician decide to pursue this course of action, however, he or she should not proceed without giving sufficient notice to allow the patient to secure another health care professional.

Moreover, the policy states, "Such decisions should be unusual and generally made only after attempts have been made to work with the family. Furthermore, a continuing relationship allows additional opportunity to discuss the issue of immunization over time."

I was recently listening to an expert at a Kansas AFP meeting who said that an average child is exposed to 2,000 to 6,000 antigens in a typical day at daycare or preschool, and the total antigen exposure for all vaccines up to age 2 is 315. I hope to use information like this to help parents make the right decision about vaccination.

The irony of the extreme success of vaccination programs is that most people -- including many physicians -- have never seen the devastating effects of vaccine-preventable illness, thus making it difficult for them to fully appreciate the benefits of vaccination. I think one of the most important things we can do is to not minimize parents’ concern. Vaccines are safe, but they are not risk-free. We should assist them in comparing the risks of the vaccine with the risks of not being immunized (for example, the risk of encephalopathy related to the measles vaccine is one in 1 million; the risk of encephalopathy associated with the disease itself is 1,000 times greater). We should give them a chance to voice their concerns and review vaccines and their risks one by one if this is what they need. And we should be prepared to address this choice each time we see them.

So you’ve educated all you can, and a parent still refuses immunizations for his or her child. What do you do? You may want to consider having parents sign a refusal waiver, stating that they understand the risks of this choice. An excellent template for this can be found on the Immunization Action Coalition website. It spells out for parents that their unvaccinated child may pose a health risk to others, that their unvaccinated child may be excluded from school, daycare and other activities in the event of an outbreak and it hammers home the potentially severe health consequences (amputation, brain damage, deafness, hospitaliza­tion, meningitis, paralysis, pneumonia, seizures and death) that could result from forgoing vaccination.

"I also found an excellent CDC handout that clearly lays out for parents the risks their unvaccinated child poses to others. The handout states, "With the decision to delay or reject vaccines comes an important responsibility that could save your child’s life, or the life of someone else." It then asks parents to "Notify the doctor’s office, urgent care facility, ambulance personnel, or emergency room staff that your child has not been fully vaccinated before medical staff has contact with your child or your family members." I plan to begin giving this to parents in my practice who are considering either refusal or delay of vaccinations.

You may want to institute a policy stating that any ill child who is unvaccinated should be taken immediately to an exam room or asked to use a back entrance to avoid contact with other patients, especially if the child has symptoms suspicious for vaccine-preventable illness, such as rash. You may want to ensure an alert is placed on the chart of any unvaccinated patient, and let staff know to notify you if these patients call in for an acute appointment so you can plan accordingly.

Perhaps the single most important thing we can do is to have a candid conversation with the parents regarding how their decision may affect their experience in your clinic, while limiting access to care as little as possible. I don’t think that there is a perfect solution, but I think that having that conversation and instituting a policy within our clinics are important and will help guide our future care of patients. I also think that respect and education can go a long way in helping parents make decisions that are in the best interests of their children, and there are no medical specialists better poised to do this than family physicians.

Dr. Oller,
Hello from a fellow Kansas physician. The simple answer to "how do you educate your patients" is educate them. The harder thing is how do you get them to change their mind? The way you get them to change their mind is TRUST. You can have all the education you want, EMR, meaningful use, PCHM, etc., but if you do not have the trust of the patient of parents their is no way you are going to change their mind unless, perhaps by chance, a close family member or friend is struck by the disease. I have basically told resistant parents that the main basic reason we give vaccines is because they prevent bad diseases and that it's much less risky to get the vaccine than to chance getting the disease. I tell them my kids got the vaccines and I treat their kids like I would treat my kids, that I respect their opinion, and that I will continue to offer the vaccines to them, and I will be glad to answer any questions they have. More often than not, over time, the parent begins to trust you more and they say yes. Be persistent, be kind, be respectful. The parents will trust you more than a handout.

Thank you for your comment Dr. Sherard. I think that it is very easy for us as physicians to forget the education piece. I find myself at times taking offense when I am questioned by a patient or a parent, and can default to the mindset of 'I went to school for this, and you are asking my opinion, so now you should do what I have recommended.' It is much harder to take the approach of patience and continued education, and mutual respect for other's opinions even when they differ drastically from our own. I appreciate you taking the time to respond, and will continue the goal of good education within my practice.

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